Provider Demographics
NPI:1093819062
Name:SU CLINICA FAMILIAR
Entity Type:Organization
Organization Name:SU CLINICA FAMILIAR
Other - Org Name:SOUTHERN CAMERON COUNTY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-365-6750
Mailing Address - Street 1:1706 TREASURE HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-8911
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4000 FM 511
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526-9492
Practice Address - Country:US
Practice Address - Phone:956-838-6346
Practice Address - Fax:956-831-3285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXA070993336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4564527OtherOTHER ID NUMBER-COMMERCIAL NUMBER